A nurse is preparing to give an SBAR report to a healthcare provider about a postoperative patient who is showing signs of respiratory distress and unstable vital signs. Which of the following actions should the nurse take when using the SBAR technique? (Select all that apply)

Rationale:
A. Proceeding with inserting the feeding tube is incorrect because the living will is a legal document that expresses the client’s wishes regarding life-sustaining treatments. A durable power of attorney for health care (proxy) cannot override explicit instructions in a valid living will. Ignoring the living will could violate the patient’s autonomy and legal rights.

B. Ignoring both the living will and proxy and providing comfort care only is incorrect because the nurse cannot make unilateral decisions about life-sustaining treatments. Care must follow legal documents, the provider’s orders, and established ethical guidelines.

C. Consulting the hospital ethics committee is incorrect as the first action. While involving the ethics committee can provide guidance in complex situations, the immediate priority is to ensure the client’s legally documented wishes are respected and communicated to the provider. Ethics consultation may follow if further clarification is needed.

D. Informing the health care provider of the conflict and advocating for honoring the client’s living will is correct. The nurse’s responsibility is to uphold the client’s autonomy and legal rights. The nurse should ensure that the provider is aware of the living will, communicate the client’s previously expressed wishes, and advocate for care that aligns with those directives. This action protects patient rights, supports ethical practice, and provides a clear, legally compliant plan for care.

Rationale:

A. The potential adverse effects of the medication is correct because documenting the possible consequences of the missed dose allows the healthcare team to monitor for complications and take preventive actions. For furosemide, missed doses could result in fluid overload, hypertension, or worsening edema. Including this information in the incident report ensures that follow-up care is guided by patient safety considerations and informs quality improvement initiatives aimed at preventing similar errors.

B. The date of the incident is correct because accurate documentation of when the event occurred is essential for legal, regulatory, and internal quality assurance purposes. It allows the facility to track patterns of missed doses or errors and supports retrospective review of contributing factors. Date documentation ensures the incident report is precise and reliable.

C. The name of the provider who prescribed the medication is incorrect because incident reports are intended to be factual records of what happened, not a tool to assign blame. Including the provider’s name could be perceived as punitive, which is contrary to the non-punitive purpose of incident reporting. The focus should remain on the event itself, not on who prescribed the medication.

D. The time the client was to receive the medication is correct because specifying the scheduled administration time clarifies the details of the error, helping staff determine the severity and urgency of follow-up interventions. Accurate timing also allows the nurse to document any necessary corrective measures and supports accountability in the medication administration process.

E. The client's vital signs is correct because including relevant clinical data provides context for assessing the potential impact of the missed dose. For example, elevated blood pressure, increased weight, or signs of fluid retention could indicate that the missed furosemide dose has affected the patient. This information helps the healthcare team prioritize interventions and ensures that patient safety remains the central focus of the report.